Form 27.1 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

BriefInfantToddlerSocialEmotionalAssessmentSAQ

30-Month Interview

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ, Phase 2g

OMB Specification


Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ


Event Category:

Time-Based

Event:

12M, 30M

Administration:

N/A

Instrument Target:

Child

Instrument Respondent:

Primary Caregiver

Domain:

Neuro-Psychosocial

Document Category:

Scored Assessment

Method:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI

Estimated Administration Time:

9 minutes

Multiple Child/Sibling Consideration:

Per Child

Special Considerations:

N/A

Version:

2.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.


Copyright © 2006 by Yale University and the University of Massachusetts.  All rights reserved.  Published and distributed exclusively by NCS Pearson, Inc. Normative data copyright © 2006 by Yale University and the University of Massachusetts.


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Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ



TABLE OF CONTENTS





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Brief Infant Toddler Social Emotional Assessment (BITSEA™) SAQ



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER



  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





BITSEA SAQ SPECIFICATIONS


BSS10000. Child's name: ____________________________________________


BSS12000/(BITSEA_DATE_COMP). Date of test  |___|___| / |___|___|  / |___|___|___|___|


SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS13000/(BITSEA_PREMATURE). Was your child born prematurely?


Label

Code

Go To

Yes

1


No

2

BSS13100


SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS13010/(BITSEA_EXPECTED_DOB). If yes, what was the expected date of birth  |___|___| / |___|___|  / |___|___|___|___|


SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS13100. Many statements describe normal feelings and behaviors, but some describe feelings and behaviors that may be problems. Please do your best to respond to every item. Please circle the ONE response that best describes your child's behavior in the LAST MONTH.


SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS14000/(BITSEA_SUCCEED). Shows pleasure when he or she succeeds (for example, claps for self).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS15000/(BITSEA_HURT_OFTEN). Gets hurt so often that you can't take your eyes off him or her.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS16000/(BITSEA_TENSE). Seems nervous, tense, or fearful.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS17000/(BITSEA_RESTLESS). Is restless and can't sit still.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS18000/(BITSEA_FLW_RULES). Follows rules.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS19000/(BITSEA_WAKES_NIGHT). Wakes up at night and needs help to fall asleep again.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS20000/(BITSEA_TANTRUM). Cries or has a tantrum until he or she is exhausted.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS21000/(BITSEA_AFRAID). Is afraid of certain places, animals or things.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS22000/(BITSEA_LESS_FUN). Has less fun than other children.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS23000/(BITSEA_LOOKS_UPSET). Looks for you (or other parent) when upset.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS24000/(BITSEA_CRIES_LEAVE). Cries or hangs onto you when you try to leave.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS25000/(BITSEA_SERIOUS). Worries a lot or is very serious.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS26000/(BITSEA_LOOKS_NAME). Looks right at you when you say his or her name.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS27000/(BITSEA_NO_REACT). Does not react when hurt.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS28000/(BITSEA_AFFECTIONATE). Is affectionate with loved ones.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS29000/(BITSEA_NO_TOUCH). Won't touch some objects because of how they feel.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS30000/(BITSEA_SLP_TROUBLE). Has trouble falling asleep or staying asleep.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS31000/(BITSEA_RUNAWAY). Runs away in public places.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS32000/(BITSEA_PLAY_OTHERS). Plays well with other children (not including brother/sister). 


PARTICIPANT INSTRUCTIONS

  • Circle Not Applicable if there is no contact with other children


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2


Not Applicable

-7



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS33000/(BITSEA_PAY_ATTN). Can pay attention for a long time (other than when watching TV).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS34000/(BITSEA_ADJCHANGE). Has trouble adjusting to changes.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS35000/(BITSEA_HURT_HELP). Tries to help when someone is hurt (for example, gives a toy).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS36000/(BITSEA_OFTEN_UPSET). Often gets very upset.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS37000/(BITSEA_GAGS_FOOD). Gags or chokes on food.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS38000/(BITSEA_IMITATE). Imitates playful sounds when you ask him or her to.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS39000/(BITSEA_REFUSE_EAT). Refuses to eat.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS40000/(BITSEA_HITS_OTHERS). Hits, shoves, kicks, or bites children (not including brother/sister).


PARTICIPANT INSTRUCTIONS

  • Circle Not Applicable if there is no contact with other children


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2


Not Applicable

-7



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS41000/(BITSEA_DESTRUCTIVE). Is destructive. Breaks or ruins things on purpose.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS42000/(BITSEA_POINT_FAR). Points to show you something far away.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS43000/(BITSEA_HIT_PARENT). Hits, bites or kicks you (or other parent).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS44000/(BITSEA_HUG_DOLL). Hugs or feeds dolls or stuffed animals.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS45000/(BITSEA_UNHAPPY). Seems very unhappy, sad, depressed, or withdrawn.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS46000/(BITSEA_HURT_PARENT). Purposely tries to hurt you (or other parent).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS47000/(BITSEA_FREEZE_UPSET). When upset, get very still, freezes, or doesn't move.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS47100. The following statements describe feelings and behaviors that can be problems for young children.  Some of the descriptions may be a bit hard to understand, especially if you have not seen the behavior in your child.  Please do your best to respond to all statements.  Please circle the ONE response that best describes your child’s behavior in the LAST MONTH.


SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS48000/(BITSEA_SPECIAL_ORDER). Puts things in a special order over and over and gets upset if he or she is interrupted.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS49000/(BITSEA_REPEAT_ACTION). Repeats the same action or phrase over and over without enjoyment. 


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS50000/(BITSEA_REPEAT_MOVEMENT). Repeats a particular movement over and over (like rocking, spinning). 


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS51000/(BITSEA_UNAWARE). Spaces out. Is totally unaware of what's happening around him or her.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS52000/(BITSEA_NO_EYE). Does not make eye contact.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS53000/(BITSEA_NO_PHYSICAL). Avoids physical contact.


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS54000/(BITSEA_HURTS_SELF). Hurts self on purpose (for example, bangs his or her head).


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS55000/(BITSEA_NOT_EDIBLE). Eats or drinks things that are not edible (like paper or paint). 


Label

Code

Go To

Not true/Rarely

0


Somewhat true/Sometimes

1


Very true/Often

2



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS56000/(BITSEA_WORRY_BEHAVE). How worried are you about your child's behavior, emotions, or relationships?


Label

Code

Go To

Not at all worried

1


A little worried

2


Worried

3


Very worried

4



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.


BSS57000/(BITSEA_WORRY_LANG). How worried are you about your child's language development?


Label

Code

Go To

Not at all worried

1


A little worried

2


Worried

3


Very worried

4



SOURCE

Brief Infant Toddler Social Emotional Assessment (BITSEA™), Margaret J. Briggs-Gowan and Alice S. Carter, Pearson Education, Inc.



FOR OFFICE USE ONLY:


FOU01000/(P_ID). Child's Participant ID: ______________________________________


FOU02000/(R_P_ID). Parent/Caregiver ID: __________________________________


Public reporting burden for this collection of information is estimated to average 9 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.

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